PRP Minor Referral Form

Date field

Consumer Name

Date of Birth

Guardian Name

Name of person with legal custody

Home address

City

State

Zip Code

Medical Assistance Number

Race

Ethnicity

Highest Educational Level:

Current frequency of treatment provided to this individual

At least 1x/week

At least 1x/2 weeks

At least 1x/month

At least 1x/3months

At least 1x/6months

How long has individual been engaged in active, documented outpatient treatment?

Less than one month

One visit in the last three months

Two or more visits in the last three months

Diagnosis

Axis I Diagnosis

Diagnosing Clinician and Title:

MINOR CLINICAL INFORMATION

A clear, current threat to the individual’s ability to be maintained in his/her customary setting

Yes No

If yes, provide of evidence of clear, current threat to the youth’s ability to be maintained in their customary setting:

An emerging/pending risk to the safety of the individual or others

Yes No

If yes, provide evidence of emerging risk to the safety of the youth or others:

Significant psychological or social impairments such as inappropriate social behaviors causing serious problems with peer relationships and/or family members.

Yes No

If yes, provide evidence of significant psychological or social impairments causing serious problems with peer relationships and/or family members:

What evidence exists to show that the current intensity of outpatient treatment for this individual is insufficient to reduce the youth’s symptoms and functional behavioral impairments:

How will PRP serve to help this youth get to age appropriate development, more independent functioning and independent living skills:

Clinical Assessment

Either complete this clinical assessment section or upload a copy of evaluation

Referral Source

Agency Name:

Therapist Name:

Address:

Email Address:

Phone Number

Fax Number

Provider NPI Number

Licensed Provider Completing this Application:

Include Name and Credentials

Date of Request

Supervisor Name, Credentials and Title: (Required if completed by an LMSW, LGPC or LGMFT)

File attachments PLEASE INCLUDE ASSESSMENT AND/OR ADDITIONAL CLINICAL INFORMATION

Add file

Please upload a file

Signature

I certify I am the mental health provider for the consumer listed on this referral form.